Provider Demographics
NPI:1083603922
Name:PODDAR, SATISH B (MD)
Entity Type:Individual
Prefix:
First Name:SATISH
Middle Name:B
Last Name:PODDAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2878 FIVE FORKS TRICKUM RD
Mailing Address - Street 2:STE 2A
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-5896
Mailing Address - Country:US
Mailing Address - Phone:678-344-8700
Mailing Address - Fax:678-344-8600
Practice Address - Street 1:2878 FIVE FORKS TRICKUM RD
Practice Address - Street 2:STE 2A
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5896
Practice Address - Country:US
Practice Address - Phone:678-344-8700
Practice Address - Fax:678-344-8600
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA43264207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000735226BMedicaid
GA000735226BMedicaid
GA11BDPPH02Medicare ID - Type Unspecified